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pATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we <br /> would like to inform you that your request for a permit or license from the City of Orono or any of its departments <br /> may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your qualification for the permit or license <br /> requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent necessary <br /> to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information may <br /> become public. <br /> 5. You have certain rights under Minnesota State Statute 13.04(see following page)to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> Md(E- 47/(//‘/ 4 .1V/e <br /> First Middle Last <br /> 3� c /24o <br /> Address <br /> OIL) c cd 767 66 ( 1-3 6 49% <br /> City State Zip Phone <br /> I understand m rghts as tated above. <br /> 4,44:101,43-- <br /> Signature <br /> Packet Last Updated: April 2016 <br /> Page 9 <br />